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The discrepancy of echocardiographic signs of right ventricular overload with the clinical picture and the level of plasma troponin concentration may underestimate the severity of the condition and lead to an inadequate choice of therapy, since all these parameters are currently determining the tactics of treatment of patients.Objective: to assess the prevalence and clinical characteristics of patients with pulmonary embolism with inconsistency of clinical, laboratory and instrumental picture.Material and methods. The course of the disease of 456 patients with pulmonary embolism was analyzed. 21 patients had a fatal outcome, the rest recovered. All patients underwent general clinical and biochemical blood tests, determination of the level of D-dimer and troponin, electrocardiography, echocardiography, ultrasound of the veins of the lower extremities, CT angiopulmonography, analysis of the results obtained.Results. It was found that among patients with high- and moderate-risk pulmonary embolism, women more often than men have an increase in the plasma concentration of troponin levels by 2.4 times, as well as a 3-fold discrepancy in the clinical and laboratory-instrumental picture with the presence of signs of right ventricular overload according to echocardiography data, which appear in dynamics. The phenomenon of "delayed echocardiography signs of overload of the right heart" is recorded in 0.8% of all patients with pulmonary embolism. At the same time, in patients with a high risk of early pulmonary embolism – associated death, its occurrence is 2.1%, and in patients with a moderately high risk – 4.4%. When comparing the prevalence of clinical and instrumental symptoms of pulmonary embolism in these patients with the data of patients with high and moderate risks of early death from pulmonary embolism, no statistically significant differences were found, including in terms of echocardiography in dynamics. The delay of еchocardiography signs of overload of the right parts of the heart" by 12–36 hours from the clinical picture, including in patients with hemodynamically significant pulmonary embolism, can be detected only with a series of еchocardiography, which allows, if necessary, timely review scope of treatment. In patients with pulmonary embolism with a pronounced lesion of the pulmonary artery, due to the rapidly progressing course of the disease, it is possible that the еchocardiography criteria of the disease do not have time to develop. In this case, an assessment of the stroke volume may play an important role, hover this parameter is non-specific for this disease.
The discrepancy of echocardiographic signs of right ventricular overload with the clinical picture and the level of plasma troponin concentration may underestimate the severity of the condition and lead to an inadequate choice of therapy, since all these parameters are currently determining the tactics of treatment of patients.Objective: to assess the prevalence and clinical characteristics of patients with pulmonary embolism with inconsistency of clinical, laboratory and instrumental picture.Material and methods. The course of the disease of 456 patients with pulmonary embolism was analyzed. 21 patients had a fatal outcome, the rest recovered. All patients underwent general clinical and biochemical blood tests, determination of the level of D-dimer and troponin, electrocardiography, echocardiography, ultrasound of the veins of the lower extremities, CT angiopulmonography, analysis of the results obtained.Results. It was found that among patients with high- and moderate-risk pulmonary embolism, women more often than men have an increase in the plasma concentration of troponin levels by 2.4 times, as well as a 3-fold discrepancy in the clinical and laboratory-instrumental picture with the presence of signs of right ventricular overload according to echocardiography data, which appear in dynamics. The phenomenon of "delayed echocardiography signs of overload of the right heart" is recorded in 0.8% of all patients with pulmonary embolism. At the same time, in patients with a high risk of early pulmonary embolism – associated death, its occurrence is 2.1%, and in patients with a moderately high risk – 4.4%. When comparing the prevalence of clinical and instrumental symptoms of pulmonary embolism in these patients with the data of patients with high and moderate risks of early death from pulmonary embolism, no statistically significant differences were found, including in terms of echocardiography in dynamics. The delay of еchocardiography signs of overload of the right parts of the heart" by 12–36 hours from the clinical picture, including in patients with hemodynamically significant pulmonary embolism, can be detected only with a series of еchocardiography, which allows, if necessary, timely review scope of treatment. In patients with pulmonary embolism with a pronounced lesion of the pulmonary artery, due to the rapidly progressing course of the disease, it is possible that the еchocardiography criteria of the disease do not have time to develop. In this case, an assessment of the stroke volume may play an important role, hover this parameter is non-specific for this disease.
To date, the search for the most informative diagnostic and prognostic echocardiographic criteria for pulmonary embolism is relevant. Aims. To conduct a critical analysis of the generally accepted echocardiographic criteria for pulmonary embolism in order to establish the most significant of them in determining the severity and outcomes of the disease. Materials and methods. The study included 42 patients with fatal pulmonary embolism, 51 patients with hemodynamically unstable and 193 with hemodynamically stable course of the disease. The prevalence of generally accepted echocardiographic criteria for overload of the right heart was assessed, followed by their significance for determining the severity of the disease and predicting its outcomes. Results. It was found that among the generally recognized echocardiographic criteria, the most significant for determining the severity of pulmonary embolism and its outcomes are: an increase in the ratio of basal sizes of the right and left ventricles more than 1.1, an increase in systolic pressure in the pulmonary artery more than 55 mm Hg, dyskinesia of the free wall of the right ventricle, flattening of the interventricular septum, a decrease in systolic excursion the plane of the tricuspid valve is less than 1.6 cm. However, all of them, except the last one, do not have high sensitivity and specificity. The significance of the currently underestimated cardiac stroke volume as a prognostic indicator of echocardiography has been established. It was determined that its decrease of less than 45 ml correlated with hemodynamic instability of the course of the disease, and less than 35 ml was associated with a fatal outcome. This indicator had high diagnostic characteristics. Conclusion. A decrease in the systolic excursion of the tricuspid valve plane of less than 1.6 cm and a decrease in the stroke volume of the heart of less than 45 ml are the most significant indicators of echocardiography in assessing the severity and prognosis of pulmonary embolism.
Vein thrombosis of the lower extremities, especially deep, is an acute condition which develops under the influence of multiple factors. In this case, the immediate threat to the patient’s life is associated with the development of acute pulmonary embolism (PE). A wide range of symptoms accompanied by the underlying disease manifestations determines patient's grave condition, complicates timely diagnosis and treatment, contributes to a poor prognosis and high mortality. Thus, the risk ratio of PE development should be assessed in all patients, regardless of age. The article provides data on the epidemiology, risk factors, clinical features and diagnosis of thromboembolic complications in real clinical practice. The paper describes a clinical case of community-acquired pneumonia in a young man with asymptomatic deep vein thrombosis of the lower extremities and the development of multiple pulmonary embolism. A combination of diseases determined the severity of patient’s state, the challenges of intravital diagnosis of the concomitant pathology and a poor prognosis due to such a combination. The diagnosis was confirmed at autopsy by the detection of various clots in the lung vascular bed.
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